Congenital defects remain the greatest contributor to infant mortality;yet, the causes for the majority of these defects are either unknown or poorly understood. Amine- and amide-containing (nitrosatable) drugs and other compounds react with nitrite in the stomach to form N-nitroso compounds. In animal models, N-nitroso compounds have been found to induce a variety of congenital malformations. The few epidemiologic studies conducted in the past have focused on the separate effects of nitrates, nitrites, and nitrosatable drugs on risk of congenital malformations without consideration of their interaction in the endogenous formation of N- nitroso compounds. This case-control study will examine the separate and joint effects of prenatal exposures to nitrates, nitrites, and nitrosatable drugs on risk of selected congenital malformations (neural tube defects, limb malformations, oral clefts, and heart defects). Cases and controls will be obtained from the National Birth Defects Prevention Study (NBDPS), a multi-center study that covers populations in 10 different states. Subjects'usual intake of dietary nitrates, nitrites, and nitrosamines will be calculated from the NBDPS food frequency questionnaire. From the NBDPS interview, medications reported taken one month preconception and during the first trimester will be classified as to their likelihood of nitrosatability based on the literature and chemical structure. The periconceptional addresses of Iowa and Texas participants will be linked to community water systems and pertinent water nitrate sampling results. For Texas participants on private wells, we will model and predict nitrate levels with a multi-dimensional flow and transport model. We will analyze the separate and joint effects of nitrosatable precursors on risk of the selected malformations. We will also examine the effects of vitamins C and E (inhibitors of nitrosation) on the relations between nitrate/nitrite intake and nitrosatable drugs and risk of selected congenital malformations. Use of over-the- counter medications is fairly common during pregnancy according to a recently published study. Several over-the-counter preparations contain nitrosatable compounds as active ingredients. The proposed study will help us understand whether pregnant women who take these types of drugs and also consume greater amounts of nitrates and nitrites are at increased risk of having offspring with birth defects. The study is also designed to examine whether higher intakes of vitamin C or E decrease these potential risks.